Title Page

  • Inspection Date

  • SCR Number where Task is to be completed

  • Client Site where Task is to be completed
  • Job / Task

  • Technician

Take 5

  • Am I fit to preform the task (aware, rested and alert)?

  • * You have selected "NO' to one of the first 5 questions. Do not proceed with work until you can answer yes by putting controls in place. If in Doubt contact your Supervisor. ***YOU ARE NOT AUTHORISED TO BEGIN WORK****

  • Controls are now in place

  • Have I walked through and assessed the the area before commencing the task

  • * You have selected "NO' to one of the first 5 questions. Do not proceed with work until you can answer yes by putting controls in place. If in Doubt contact your Supervisor. ***YOU ARE NOT AUTHORISED TO BEGIN WORK****

  • Controls are now in place

  • Am I using the correct tools / PPE for the task?

  • * You have selected "NO' to one of the first 5 questions. Do not proceed with work until you can answer yes by putting controls in place. If in Doubt contact your Supervisor. ***YOU ARE NOT AUTHORISED TO BEGIN WORK****

  • Controls are now in place

  • Have I put all SAFE Controls in Place to ensure that I dont breach a Cardinal Rule

  • * You have selected "NO' to one of the first 5 questions. Do not proceed with work until you can answer yes by putting controls in place. If in Doubt contact your Supervisor. ***YOU ARE NOT AUTHORISED TO BEGIN WORK****

  • Controls are now in place

  • Do I know what to do in an emergency

  • * You have selected "NO' to one of the first 5 questions. Do not proceed with work until you can answer yes by putting controls in place. If in Doubt contact your Supervisor. ***YOU ARE NOT AUTHORISED TO BEGIN WORK****

  • Controls are now in place

Assess for Potential Hazzards

  • 1-HAZARDOUS ENERGY ELECTRICAL - Do I need to isolate and test for Zero Energy State using LOTO and Volt Alert? ***For Security Systems under 50v DC ZES is not required***

  • - Hazard Identified - Hazardous Electrical Energy. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

  • Hazardous Electrical Energy.
  • Hazard Identified

  • Controls you implemented to reduce the risk

  • Safe to continue?

  • Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

  • I have called my Supervisor for advice and guidance

  • Hazard Identified

  • Controls you implemented to reduce the risk

  • Hazard Identified

  • 2- HAZARDOUS ENERGY MECHANICAL - Can I be harmed by stored energy (water, gas under pressure) heat, fumes, chemicals?

  • - Hazard Identified - Hazardous Mechanical Energy. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

  • Hazardous Mechanical Energy.
  • Hazard Identified

  • Controls you implemented to reduce the risk

  • Safe to continue?

  • Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

  • I have called my Supervisor for advice and guidance

  • 3- FALL PROTECTION - Can I fall from height?

  • - Hazard Identified - Working at Heights. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environments

  • Working at Heights.
  • Hazard Identified

  • Controls you implemented to reduce the risk

  • Safe to continue?

  • Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

  • I have called my Supervisor for advice and guidance

  • 4- WORKING UNDER SUSPENDED LOADS - Am I concerned that something may fall on me or strike me?

  • - Hazard Identified - Suspended Loads. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

  • Working Under Suspended Loads
  • Hazard Identified

  • Controls you implemented to reduce the risk

  • Safe to continue?

  • Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

  • I have called my Supervisor for advice and guidance

  • 5- Could there be uncontrolled movement?

  • - Hazard Identified - Uncontrolled Movement. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

  • Uncontrolled Movement
  • Hazard Identified

  • Controls you implemented to reduce the risk

  • Safe to continue?

  • Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

  • I have called my Supervisor for advice and guidance

  • 6- GRAVITY - Can I slip or trip on anything?

  • - Hazard Identified - Slips Trips and Falls. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

  • Gravity
  • Hazard Identified

  • Controls you have implemented to reduce the risk

  • Safe to continue?

  • Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

  • I have called my Supervisor for advice and guidance

  • 7- MANUAL HANDLING - Can I strain or over exert myself?

  • - Hazard Identified - Manual Handling . Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

  • Manual Handling
  • Hazard Identified

  • Controls you have implemented to reduce the risk

  • Safe to continue?

  • Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

  • I have called my Supervisor for advice and guidance

  • 8- LINE OF FIRE - Can I be caught in, on, or between anything?

  • - Hazard Identified - Line of Fire. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

  • Line of Fire
  • Hazard Identified

  • Controls you have implemented to reduce the risk

  • Safe to continue?

  • Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

  • I have called my Supervisor for advice and guidance

  • 9- Can I damage any equipment?

  • - Hazard Identified - Damage to Equipment. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

  • Damage to Equiptment
  • Hazard Identified

  • Controls you have implemented to reduce the risk

  • Safe to continue?

  • Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

  • I have called my Supervisor for advice and guidance

  • 10- Do I need to communicate to my workmates the risks associated with this task?

  • Communication
  • What Needs to Be Communicated?

  • How will this be communicated?

  • Safe to continue?

  • Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

  • I have called my Supervisor for advice and guidance

  • ENVIRONMENT - Is there a chance I could spill or pollute something?

  • - Hazard Identified - Environment. Scan, Assess, Fix, Execute: What effect could the hazard have on people property and the Environment

  • 11- Enviroment
  • Hazard Identified

  • Controls you have implemented to reduce the risk

  • Safe to continue?

  • Call your Supervisor for Assistance ***YOU ARE NOT AUTHORISED TO BEGIN WORK***

  • I have called my Supervisor for advice and guidance

Complete

Thank you for Completing this Take 5! You can now undertake your task.

  • Remember, if conditions change you will need to update this assesment

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.